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1 TeesRep - Teesside's Research Repository Surgical versus non-surgical interventions in people with adolescent idiopathic scoliosis Item type Authors Citation DOI Publisher Journal Additional Link Rights Article Bettany-Saltikov, J. A. (Josette); Weiss, H. (Hans- Rudolph); Chockalingam, N. (Nachiappan); Taranu, R. (Razvan); Srinivas, S. (Shreya); Hogg, J. (Julie); Whittaker, V. (Victoria); Kalyan, R. V. (Raman); Arnell, T. (Tracey) Bettany-Saltikov, J. A., Weiss, H., Chockalingam, N., Taranu, R., Srinivas, S., Hogg, J., Whittaker, V., Kalyan, R. V., Arnell, T. (2015) 'Surgical versus non-surgical interventions in people with adolescent idiopathic scoliosis' Cochrane Database of Systematic Reviews 2015; Issue 4. Art. No.: CD DOI: / CD pub / CD pub2 Wiley Cochrane Database of Systematic Reviews pub2/full Author can archive publisher's version/pdf on institutional repository or funder's designated repository, including PubMed Central after 12 months embargo. For full details see [Accessed: 22/05/2015] Downloaded 15-Oct :15:58 Link to item TeesRep - Teesside University's Research Repository -

2 This full version, available on TeesRep, is the published version of: Bettany-Saltikov, J. A., Weiss, H., Chockalingam, N., Taranu, R., Srinivas, S., Hogg, J., Whittaker, V., Kalyan, R. V., Arnell, T. (2015) 'Surgical versus non-surgical interventions in people with adolescent idiopathic scoliosis' Cochrane Database of Systematic Reviews 2015; Issue 4. Art. No.: CD DOI: / CD pub2. For the published version see: / CD pub2 When citing this source, please use the final published version as above This document was downloaded from All items in TeesRep are protected by copyright, with all rights reserved, unless otherwise indicated. TeesRep: Teesside University's Research Repository

3 Surgical versus non-surgical interventions in people with adolescent idiopathic scoliosis (Review) Bettany-Saltikov J, Weiss HR, Chockalingam N, Taranu R, Srinivas S, Hogg J, Whittaker V, Kalyan RV, Arnell T This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2015, Issue 4

4 T A B L E O F C O N T E N T S HEADER ABSTRACT PLAIN LANGUAGE SUMMARY SUMMARY OF FINDINGS FOR THE MAIN COMPARISON BACKGROUND OBJECTIVES METHODS RESULTS Figure DISCUSSION AUTHORS CONCLUSIONS ACKNOWLEDGEMENTS REFERENCES CHARACTERISTICS OF STUDIES DATA AND ANALYSES APPENDICES CONTRIBUTIONS OF AUTHORS DECLARATIONS OF INTEREST SOURCES OF SUPPORT DIFFERENCES BETWEEN PROTOCOL AND REVIEW i

5 [Intervention Review] Surgical versus non-surgical interventions in people with adolescent idiopathic scoliosis Josette Bettany-Saltikov 1, Hans-Rudolf Weiss 2, Nachiappan Chockalingam 3, Razvan Taranu 4, Shreya Srinivas 5, Julie Hogg 1, Victoria Whittaker 1, Raman V Kalyan 6, Tracey Arnell 7 1 School of Health and Social Care, University of Teesside, Middlesbrough, UK. 2 Spinal Deformities Rehabilitation Services, Orthopedic Practice, Gensingen, Germany. 3 Faculty of Health, Staffordshire University, Stoke-on-Trent, UK. 4 Department of Trauma and Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Ashington, UK. 5 Northern Deanery, James Cook University Hospital, Middlesbrough, UK. 6 James Cook University Hospital, Middlesbrough, UK. 7 Newcastle College, Newcastle, UK Contact address: Josette Bettany-Saltikov, School of Health and Social Care, University of Teesside, Victoria Road, Middlesbrough, Cleveland, TS13BA, UK. j.b.saltikov@tees.ac.uk. Editorial group: Cochrane Back Group. Publication status and date: New, published in Issue 4, Review content assessed as up-to-date: 8 August Citation: Bettany-Saltikov J, Weiss HR, Chockalingam N, Taranu R, Srinivas S, Hogg J, Whittaker V, Kalyan RV, Arnell T. Surgical versus non-surgical interventions in people with adolescent idiopathic scoliosis. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD DOI: / CD pub2. Background A B S T R A C T Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine. While AIS can progress during growth and cause a surface deformity, it is usually not symptomatic. However, if the final spinal curvature surpasses a certain critical threshold, the risk of health problems and curve progression is increased. Interventions for the prevention of AIS progression include scoliosis-specific exercises, bracing, and surgery. The main aims of all types of interventions are to correct the deformity and prevent further deterioration of the curve and to restore trunk asymmetry and balance, while minimising morbidity and pain, allowing return to full function. Surgery is normally recommended for curvatures exceeding 40 to 50 degrees to stop curvature progression with a view to achieving better truncal balance and cosmesis. Short-term results of the surgical treatment of people with AIS demonstrate the ability of surgery to improve various outcome measures. However there is a clear paucity of information on long-term follow-up of surgical treatment of people with AIS. Objectives To examine the impact of surgical versus non-surgical interventions in people with AIS who have severe curves of over 45 degrees, with a focus on trunk balance, progression of scoliosis, cosmetic issues, quality of life, disability, psychological issues, back pain, and adverse effects, at both the short term (a few months) and the long term (over 20 years). Search methods We searched the Cochrane Back Review Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, four other databases, and three trials registers up to August 2014 with no language limitations. We also checked the reference lists of relevant articles and conducted an extensive handsearch of the grey literature. 1

6 Selection criteria We searched for randomised controlled trials (RCTs) and prospective controlled trials comparing spinal fusion surgery with non-surgical interventions in people with AIS with a Cobb angle greater than 45 degrees. We were interested in all types of instrumented surgical interventions with fusion that aimed to provide curve correction and spine stabilisation. Data collection and analysis We found no RCTs or prospective controlled trials that met our inclusion criteria. Main results We did not identify any evidence comparing surgical to non-surgical interventions for AIS with severe curves of over 45 degrees. Authors conclusions We cannot draw any conclusions. P L A I N L A N G U A G E S U M M A R Y Surgical treatment compared to non-surgical treatment (braces, exercise, or observation) for teens with idiopathic scoliosis Background Scoliosis is a condition where the spine is curved in three dimensions (from the back the spine appears to be shaped like a c or an s ). It is often idiopathic, or of unknown cause. The most common type of scoliosis, adolescent idiopathic scoliosis (AIS), is discovered around 10 years of age or older, and is defined as a curve that measures at least 10 degrees (known as a Cobb angle, which is measured on an x-ray). People with AIS usually have no symptoms, however the resulting surface deformity frequently negatively impacts adolescents. In addition, increased curvature of the spine can present health risks in adulthood. Different types of treatment, including physical therapy, bracing, and surgery, are advocated depending on the magnitude of the curvature and area affected, truncal balance, general health, level of function and satisfaction, and patient s and parent s treatment desire. Surgery is normally recommended in curvatures exceeding 40 to 50 degrees to stop the progression of the curvature. Short-term results of surgical treatment are improvements on outcome measures relating to self image, some functional aspects, and pain. However, the structured long-term follow-up needed to make meaningful conclusions is lacking. Recent papers highlight the long-term complications of surgery, while other papers postulate that the medium- and long-term complication rates following modern scoliosis surgery are low when compared to older techniques. Study characteristics We searched the literature for both randomised controlled trials and prospective non-randomised studies with a control group examining the effects of surgical versus non-surgical treatments for teens with idiopathic scoliosis. The evidence is current to August Key results We identified no evidence examining the effectiveness of surgical interventions compared to non-surgical interventions for people with AIS. As a result, we cannot draw any conclusions regarding the benefits or harms of these treatments. 2

7 S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation] Surgical interventions compared with non-surgical Interventions in people with adolescent idiopathic scoliosis Patient or population: Adolescent Idiopathic Scoliosis Settings: Anywhere Intervention: Surgical intervention Comparison: Non-surgical intervention Outcomes Illustrative comparative risks*(95% CI) Relative effect (95% CI) Assumed risk Non-surgical interventions Corresponding risk Surgical Interventions No of Participants (studies) Quality of the evidence (GRADE) Comments Changes in trunk balance See comment See comment Not estimable 0 See comment We identified no randomised or non-randomised prospective studies with a control group Progression of scoliosis See comment See comment Not estimable 0 See comment We identified no randomised or non-randomised prospective studies with a control group Cosmetic issues See comment See comment Not estimable 0 See comment We identified no randomised or non-randomised prospective studies with a control group 3

8 Quality of life See comment See comment Not estimable 0 See comment We identified no randomised or non-randomised prospective studies with a control group Back pain See comment See comment Not estimable 0 See comment We identified no randomised or non-randomised prospective studies with a control group Disability See comment See comment Not estimable 0 See comment We identified no randomised or non-randomised prospective studies with a control group Psychological issues See comment See comment Not estimable 0 See comment We identified no randomised or non-randomised prospective studies with a control group CI: confidence interval GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Lowquality:Furtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandislikelytochangetheestimate. Very low quality: We are very uncertain about the estimate. 4

9 B A C K G R O U N D Scoliosis is a complex, three-dimensional deformity of the spine that comprises a lateral curvature in the frontal plane (this is a vertical plane that divides the body into front and back halves), thoracic lordosis in the sagittal plane (this is a vertical plane that divides the body into right and left halves) and a posterior rib hump, which is produced by rotation of the vertebrae in the transverse plane (horizontal plane); this results in the posterior elevation of the rib cage on the convex side of the curve and a depression on the concave side (Bradford 1987). These underlying skeletal changes are usually reflected by a change in back shape, the unsightly shape of which is generally more of a concern to the patient than is the underlying skeletal deformity (White 1990). If left untreated, the condition results in altered spinal mechanics and degenerative changes that lead to pain, loss of spinal mobility, and possible loss of function or disability. Cardiac and respiratory dysfunction may accompany these symptoms, depending on the time of onset of the deformity (White 1990). There are also psychological consequences that result from the unsightly and deformed shape of the back: A restricted social life, lower marriage rate, higher divorce rate, fewer children per marriage, and increased psychiatric consultations, including eating disorders and increased suicide rate, have all been reported (Freidel 2002). Scoliosis can also occur secondary to certain diseases and conditions that affect the nervous and muscular systems of the body. However, most cases of scoliosis (80% to 90%) are idiopathic, meaning the underlying cause is unknown. The most common form of scoliosis is adolescent idiopathic scoliosis (AIS), which appears in late childhood or adolescence -- a period of rapid growth (Kanayama 1996; Stokes 1996). According to the Scoliosis Research Society and the International Society on Scoliosis Orthopaedic Rehabilitation and Treatment (Negrini 2012), the prevalence of AIS in the general population is 2% to 3%. Nearly 10% of people with AIS will require some form of treatment, and up to 0.1% will eventually require surgery (Lonstein 2006). AIS is more common in females. While it does not typically cause any health problems during growth, the resulting surface deformity frequently has a negative impact on adolescents that can give rise to quality-of-life issues and, in the worst cases, psychological disturbances (Reichel 2003). As the condition is most often painless, early diagnosis is difficult, especially in countries where school scoliosis screening is not implemented. External change to the body shape is minimal in the early stages, and most changes in back shape occur predominantly on the back of the trunk, which is difficult for patients to see, and can be concealed by clothing (Roaf 1980). Treatment of AIS is determined by the deformity itself. As most people with AIS progress during growth, the main aims of all interventions are to limit or stop the curvature progression, restore trunk balance (Goldberg 2002; Asher 2006), and prevent the long-term consequences of the deformity. Description of the condition Description of the intervention Interventions for the prevention of AIS progression include scoliosis-specific exercises, bracing, and surgery (Lenssinck 2005; Negrini 2005; Rowe 1997; Weiss 2006a). The goals of all interventions are to correct the deformity and prevent further deterioration of the curve (that is prevent progression) and to restore trunk symmetry and balance, while minimising morbidity and pain, allowing return to full function (Bridwell 1999; Lonstein 2006). Non-surgical interventions Scoliosis-specific exercises consist of individually adapted exercises that are taught to patients in a centre that is dedicated to scoliosis treatment. Patients learn an exercise protocol that is personalised according to their own medical and physiotherapeutic evaluation. On the other hand, usual generalised physiotherapy is more generic, consisting of low-impact stretching and strengthening activities like yoga, but can include many different exercise protocols. Bracing is defined as the application of external supports to the trunk; these are usually rigid and are applied with the aim of achieving maximum correction of the pathological curve (Rigo 2006a). Treatment commences when the curve is diagnosed as progressive, or when it exceeds a threshold of 30 degrees Cobb angle (Lonstein 2006; Negrini 2005; Weiss 2006a). Braces generally need to be worn for a considerable period of time per day (at least 20 hours) over several years until the end of bone growth, which usually occurs at 16 years of age for girls and 18 years of age for boys (Katz 2001). This causes a significant negative impact on the quality of life of children and adolescents (Climent 1999; Fallstrom 1986; Noonan 1997). Surgical interventions Fusion is generally considered to be necessary when AIS exceeds a certain degree (approximately 45 to 50 degrees), when previous treatments have failed, or when AIS causes symptoms, but indications vary widely according to the preference of the treating physician/surgeon (Dolan 2007). The literature describes a large multitude and variety of interventions (Maruyama 2008), including different surgical approaches (posterior, anterior, or combined) and various types of metal implant systems. Posterior fusion with instrumentation has long been a standard for the surgical treatment of AIS (Lonner 2007; Maruyama 2008). The Harrington technique and instrumentation was introduced in the 1960s, followed by the Cotrel-Dubousset instrumentation technique in 1980s (Kadoury 2009). The last two decades have 5

10 seen a gradual progression or shift of usage from hook-based instrumentation systems to hybrid-based systems (hooks and pedicle screws) to all-pedicle screw systems with more anchors to the spine. This shift has enabled greater and better anchorage and correction manoeuvres and reduced the implant failure rate (Olgun 2013). Anterior instrumentation surgery was previously favoured for thoracolumbar and lumbar scoliosis, as it enabled shorter fusion levels. However, since the recent introduction and usage of all-pedicle screw construct posterior surgery, the use of anterior surgery has been limited (Maruyama 2008). Modern surgical techniques follow the principles of segmental spinal instrumentation, where each vertebra of the spine is attached to a metal rod by means of screws or hooks. Modern surgical techniques are believed to reliably provide a better arrest of progression of the deformity and achieve greater correction of the curves in the coronal plane (30% to 90%) with minimal loss at follow-up (Westrick 2011). Furthermore, these techniques also achieve a spontaneous partial correction of the compensatory curves and improve appearance. A recent prospective multicentre study on the outcomes of surgical treatment using participantbased outcomes demonstrates the ability of surgery to improve some outcome measures at the two-year postsurgical follow-up (Merola 2002). However, there is a lack of high-quality prospective studies with a control group on long-term follow-up. All types of spinal fusion surgery are associated with significant risk, both in the short term and long term. The short-term risk for spinal fusion surgery is estimated to be approximately 5%, while longterm risks over a lifetime are estimated to be much higher (Weiss 2008a), with reoperation rates ranging from 6% to 29% (Asher 2006). A recently published meta-analysis on 1565 participants with a mean follow-up of 14.9 years demonstrated a reoperation rate between 0% to 8.3% (Lykissas 2013), the highest incidence being related to the use of Harrington rods and the lowest to allpedicle screws. The same study reported a mean infection rate of 3.6%, the lowest incidence being encountered with the use of all-pedicle screws (1.18%) and the highest with Harrington rods (5.5%). How the intervention might work Scoliosis-specific exercises can be used in three main clinical scenarios: (1) as the primary treatment of AIS for mild curves, (2) in conjunction with braces for moderate curves, and (3) during adulthood if the scoliosis curves exceed certain thresholds (Romano 2012). In the treatment of mild scoliosis, scoliosis-specific exercises can be used on curves greater than 10 to 15 degrees but less than 25 or 30 degrees Cobb. These intense three-dimensional spine-and-rib-cage-specific exercises are used to try to limit the progression of the curve and thereby avoid the need for a brace. This critical Cobb angle is generally regarded as the threshold for brace prescription (Lonstein 2006; Weiss 2006b). The key objectives of physical exercise in mild cases of AIS include stabilisation of the spine, three-dimensional auto-correction of the pelvis, rib cage, and shoulders together with isometric muscle contractions (Romano 2012; Weiss 2006b). Braces use external corrective forces to correct the trunk; this is usually achieved with the use of rigid supports. However, some braces (known as soft braces) are made of material similar to elastic bands that is comparable with materials used in physical therapy treatments (Coillard 2003; Rigo 2006a). The mechanical forces of the brace are used to straighten the spine and de-rotate the pelvis and shoulders to bring the whole body into normal alignment. Negrini 2010 states that the external and proprioceptive inputs due to bracing change the unnatural loading on the spine and rib cage, decrease asymmetrical movements, and improve neuromuscular control; this facilitates proper spinal growth, neuromotor reorganization, and changes in motor behaviours (Castro 2003; Coillard 2002; Grivas 2008; Lupparelli 2002; Negrini 2006c; Odermatt 2003; Smania 2008; Stokes 2006; Weiss 2004). Unfortunately, most braces have the disadvantage of not being very comfortable to wear, especially for long periods. Furthermore, weakening of the back muscles may occur if bracing is not combined with scoliosisspecific exercises. The aim of surgical treatment of the scoliotic spine is to correct the spinal curvature (reduction of the Cobb angle) and fuse the spine with the help of bone grafts that allow the spine to heal to a solid and stable bone fusion mass (spinal fusion), supported by the instrumentation (Haher 2003). Why it is important to do this review After conducting a comprehensive literature search, we identified only two key reviews that addressed surgical versus non-surgical interventions for AIS (Hawes 2006a; Weiss 2008b). Hawes 2006a was a very comprehensive narrative review, and hence had all the biases and limitations generally associated with such reviews (Bettany-Saltikov 2012). Weiss 2008b, although entitled a systematic review, did not in actuality meet the criteria for a systematic review; the search strategy as well as the precise methods used to identify and select papers were not detailed. Furthermore, it was unclear which primary papers were included and/or excluded, and the processes for the methodological evaluation and data extraction of included primary papers, if undertaken, were not described. The significant limitations of these two reviews strongly highlighted the need for a state-of-the-art Cochrane review. Additionally, it was important to undertake this review so that people with AIS with severe curves and their parents understand both the shortand long-term effects, as well as the side effects and consequences, of surgical and non-surgical interventions, and can make evidencebased decisions. 6

11 O B J E C T I V E S To examine the impact of surgical versus non-surgical interventions in people with AIS who have severe curves of over 45 degrees, with a focus on trunk balance, progression of scoliosis, cosmetic issues, quality of life, disability, psychological issues, back pain, and adverse effects, at both the short term (a few months) and the long term (over 20 years). M E T H O D S Criteria for considering studies for this review Types of studies For the primary analysis we intended to combine the results of randomised control trials (RCTs) and quasi-randomised control trials (QRCTs). We also planned to include prospective non-randomised studies (NRSs) with a control group because we anticipated finding very few RCTs. We planned to include primary studies that compared surgical interventions with non-surgical interventions. Types of participants We intended to include people with AIS who were diagnosed and managed when they were between 10 and 18 years of age, with a Cobb angle greater than 45 degrees (Negrini 2012). We planned to exclude studies on participants with early-onset scoliosis (infant or juvenile) and scoliosis secondary to other conditions. Types of interventions We intended to include all types of instrumented surgical interventions with fusion that aimed to provide curve correction and spine stabilisation. We planned to exclude studies describing noninstrumented spinal correction and fusion, because the outcomes these interventions provide have been shown to be no better than those seen with untreated scoliosis (Bradford 1987). We aimed to compare instrumented surgical interventions with different types of non-surgical treatments, such as scoliosis-specific exercises, bracing, physiotherapy, chiropractic treatment, electrical stimulation, and other non-surgical interventions for people with AIS with severe curves of over 45 degrees. Types of outcome measures We planned to examine outcomes (primary and secondary) measured in the immediate term (perioperative to six weeks postoperative), the short term (results at the end of bone growth), within two years, and over the long term (results in adulthood and in old age). Primary outcomes 1. Change in trunk balance, measured in centimetres: i) Frontal (coronal) balance (refers to the plane that divides the body into front and back halves); ii) Lateral trunk shift; and iii) Apical vertebral translation. 2. Progression of scoliosis, measured by: i) Cobb angle in degrees (absolute values); ii) Angle of trunk rotation in degrees (absolute values); and iii) Number of participants who progressed by more than 5 degrees Cobb (5 degrees Cobb is the standard clinical measure reported within various research papers and commonly used in clinical practice). 3. Cosmetic issues, as measured by: i) Validated scales or questionnaires: Walter Reed Visual Assessment Scale (Pineda 2006), Spinal Appearance Questionnaire (Sanders 2007), Trunk Appearance Perception Scale (Bago 2010); and ii) Topographic measurements: Integrated Shape Imaging System or Integrated Shape Imaging System 2 (Berryman 2008), Quantec (Oxborrow 2000), Formetric (Knott 2010), measured in angles and millimetres. 4. Quality of life as measured by: i) Generic questionnaires: 36-Item Short Form Health Survey; ii) Scoliosis-specific questionnaires: Scoliosis Research Society-22 (Asher 2003); iii) Bad Sobernheim Stress Questionnaire (Weiss 2006b); and iv) Brace Questionnaire (Vasiliadis 2006). 5. Psychological issues as measured by: i) Specific psychological questionnaires evaluating such concepts as self esteem, self image, etc., using specific questionnaires and subscales of Scoliosis Research Society-22, Brace Questionnaire, 36-Item Short Form Health Survey. 6. Back pain and disability as measured by: i) Validated scales measuring pain intensity and pain duration, such as the visual analogue scale, McGill Pain Questionnaire, and other validated specific questionnaires, as well as use of medication. Secondary outcomes Secondary outcomes were any adverse effects reported in any of the included studies, such as blood loss, pseudarthrosis (a false joint where the bone has not healed adequately), deep wound infection, neurological complications, delayed infections, pedicle screw misplacement, delayed paraparesis (weakness or partial paralysis in the lower limbs) as well as the loss of normal spinal function and decompensation (spinal imbalance), increased spinal deformity and death. We planned to report any adverse events in our 7

12 review, whether or not they were listed here. Data collection and analysis Search methods for identification of studies Electronic searches We searched the following electronic databases from inception to August Cochrane Back Review Group Trials Register (Cochrane Register of Studies (CRS)) Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) MEDLINE (OvidSP, 1946 to July Week 5, 2014) and MEDLINE In-Process & Other Non-Indexed Citations (OvidSP, 7 August 2014) EMBASE (OvidSP, 1980 to 2014 Week 31) Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO, 1981 to August 2014) PsycINFO (OvidSP, 2002 to August Week 1, 2014) Physiotherapy Evidence Database (PEDro, 1929 to August 2014) PubMed (1946 to August 2014) The search strategy combined the study design filter for observational studies adapted from the Scottish Intercollegiate Guidelines Network with the Cochrane Highly Sensitive Search Strategy for identifying RCTs in MEDLINE, so that the search captured all study designs. We combined the study design terms with blocks of search terms for the disorder and the interventions. The strategy included subject headings (for example MeSH) and was adapted for the other databases (see Appendix 1 and Appendix 2). Selection of studies We first developed a study selection form on the basis of the inclusion criteria. This was piloted and tested for both intraobserver and interobserver reliability by two review authors, who then independently screened the search results by reading the titles and abstracts. Potentially relevant studies were obtained in full text, and once again they were independently assessed for inclusion by two review authors, who resolved any disagreement through discussion. A third review author was contacted if disagreements persisted. If a review author was also the author of a paper, another review author who had not authored any of the papers undertook the selection. We did not select any papers before 1980 because research done on older instrumentation may not have been relevant. Although clear advances in the materials and the design of spinal instrumentation have been made since 1980, the surgical approach and training may still be the same. We did not find any relevant RCTs, QRCTs, or NRSs with a control group. As such, we were unable to carry out most of the pre-stated methodology. We have therefore described the planned methods in Appendix 3. Data extraction and management See Appendix 3 for planned methodology. Assessment of risk of bias in included studies See Appendix 3 for planned methodology. Searching other resources The following strategies were also used. Screening the reference lists of all relevant papers. Searching the main electronic sources of ongoing trials: UK Clinical Trials Gateway (UKCTG), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (see Appendix 2). Searching the grey literature, including conference proceedings and PhD theses completed since For the latter, we searched the Electronic Theses Online Service ( EThOS) provided by the British Library, which is an open access single point digital repository of UK research theses. See Appendix 2 for the EThOS search strategy. Contacting investigators and authors in the field for information on unpublished or incomplete trials. All searches included non-english language literature. Measures of treatment effect See Appendix 3 for planned methodology. Unit of analysis issues See Appendix 3 for planned methodology. Dealing with missing data See Appendix 3 for planned methodology. Assessment of heterogeneity See Appendix 3 for planned methodology. Assessment of reporting biases See Appendix 3 for planned methodology. 8

13 Data synthesis See Appendix 3 for planned methodology. Subgroup analysis and investigation of heterogeneity See Appendix 5 for planned methodology. Sensitivity analysis See Appendix 3 for planned methodology. Clinical relevance of results See Appendix 3 for planned methodology. R E S U L T S Description of studies Results of the search Our search of databases identified 4798 records. After screening the records, we assessed eight full-text articles, which we excluded because they were either retrospective cohort studies with a control group or retrospective case studies with a control group. There were no prospective studies with a control group (see study flow diagram, Figure 1). 9

14 Figure 1. Study flow diagram. 10

15 Excluded studies The eight studies we excluded were all retrospective studies with a control group (Anderson 2006; Bunge 2007; Danielsson 2001; Danielsson 2001a; Danielsson 2001b; Danielsson 2003; Danielsson 2006; Pehrsson 2001). See Characteristics of excluded studies tables. Risk of bias in included studies We evaluated no studies for methodological quality. Quality of the evidence There is currently no randomised or non-randomised trial-based evidence from prospective studies with a control group comparing the effectiveness of surgical to non-surgical interventions for people with AIS with severe curves of over 45 degrees. Potential biases in the review process The most important potential bias is having missed any prospective controlled studies. However, given our extensive literature search, it is unlikely that we have missed any studies. Effects of interventions See: Summary of findings for the main comparison We did not identify any evidence comparing surgical to non-surgical interventions for people with AIS with severe curves of over 45 degrees (Summary of findings for the main comparison) Agreements and disagreements with other studies or reviews There is currently no randomised or non-randomised trial-based evidence from prospective studies with a control group that could be compared with other studies. A U T H O R S C O N C L U S I O N S D I S C U S S I O N Summary of main results We did not identify any evidence of effectiveness of surgical compared to non-surgical interventions for people with AIS with severe curves of over 45 degrees. Overall completeness and applicability of evidence This review is technically considered to be an empty review as we did not find any studies that met all the inclusion criteria. Nonetheless, this review provides important information regarding research gaps in this field, which is consistent with previously published reviews on this topic (Weiss 2008c; Weiss 2013). Implications for practice In conclusion, we did not identify any evidence comparing surgical to non-surgical interventions for people with AIS with severe curves of over 45 degrees. We were therefore unable to draw any conclusions in this review. Implications for research In conclusion, we did not identify any evidence comparing surgical to non-surgical interventions for people with AIS with severe curves of over 45 degrees. We were therefore unable to draw any conclusions in this review. A C K N O W L E D G E M E N T S We would like to thank Rachel Couban, Cochrane Back Review Group Trials Search Co-ordinator, for her help with development of the search strategies. We would also like to thank Dr Teresa Marin for her help with all our queries in completing this review. 11

16 R E F E R E N C E S References to studies excluded from this review Anderson 2006 {published data only} Anderson MO, Christenesen SB, Thomsen K. Outcome at 10 years after treatment for adolescent idiopathic scoliosis. Spine 2006;31(3): Bunge 2007 {published data only} Bunge EM, Juttmann RE, De Kleuver M, Van Biezen FC, De Koning HJ. Health-related quality of life in patients with adolescent idiopathic scoliosis after treatment: shortterm effects after brace or surgical treatment. European Spine Journal 2007;16(1):83 9. Danielsson 2001 {published data only} Danielsson AJ, Nachemson AL. Radiologic findings and curve progression 22 years after treatment for adolescent idiopathic scoliosis. Spine 2001;26(5): Danielsson 2001a {published data only} Danielsson AJ, Nachemson AL. Childbearing, curve progression, and sexual function in women 22 years after treatment for adolescent idiopathic scoliosis. Spine 2001;26 (13): Danielsson 2001b {published data only} Danielsson AJ, Wiklund I, Pehrsson K, Nachemson AL. Health-related quality of life in patients with adolescent idiopathic scoliosis: a matched follow-up at least 20 years after treatment with brace or surgery. European Spine Journal 2001;10(4): Danielsson 2003 {published data only} Danielsson AJ, Nachemson AL. Back pain and function 22 years after brace treatment for adolescent idiopathic scoliosis: a case-control study - part 1. Spine 2003;28(18): Danielsson 2006 {published data only} Danielsson AJ, Romberg K, Nachemson AL. Spinal range of motion, muscle endurance, and back pain and function at least 20 years after fusion or brace treatment for adolescent idiopathic scoliosis. Spine 2006;31(3): Pehrsson 2001 {published data only} Pehrsson K, Danielson A, Nachemson A. Pulmonary function in adolescent idiopathic scoliosis: a 25 year follow up after surgery or start of brace treatment. Thorax 2001;56 (5): Additional references Asher 2003 Asher M, Min Lai S, Burton D, Manna B. The reliability and concurrent validity of the Scoliosis Research Society 22 patient questionnaire for idiopathic scoliosis. Spine 2003; 28(1):63 9. Asher 2006 Asher M, Burton D. Adolescent idiopathic scoliosis: natural history and long term treatment effects. Scoliosis 2006;1(1): 2. [DOI: / ] Bago 2010 Bago J, Sanchez-Raya J, Sanchez Perez-Grueso F, Climent J. The Trunk Appearance Perception Scale (TAPS): a new tool to evaluate subjective impression of trunk deformity in patients with idiopathic scoliosis. Scoliosis 2010;5(1):6. Berryman 2008 Berryman F, Pynsent P, Fairbank J, Disney S. A new system for measuring three-dimensional back shape in scoliosis. European Spine Journal 2008;17(5): Bettany-Saltikov 2012 Bettany-Saltikov. How to Do a Systematic Review: A Step by Step Guide for Nursing Practice. 1st Edition. London: Open University Press, Bradford 1987 Bradford D, Lonstein J, Moe J, Ogilvie J, Winter R. Moe s Textbook of Scoliosis and Other Spinal Deformities. 2. Philadelphia: Saunders, Bridwell 1999 Bridwell K. Surgical treatment of idiopathic adolescent scoliosis. Spine (Focus Issue) 1999;24(24): Castro 2003 Castro F Jr. Adolescent idiopathic scoliosis, bracing and the Hueter-Volkmann principle. Spine 2003;3(3): Climent 1999 Climent J, Sanchez J. Impact of the type of brace on the quality of life of adolescents with spine deformities. Spine 1999;24(18): Coillard 2002 Coillard C, Leroux M, Badeaux J, Rivard C. SPINECOR: a new therapeutic approach for idiopathic scoliosis. Studies in Health Technology and Informatics 2002;88(1): Coillard 2003 Coillard C, Leroux M, Zabjek K, Rivard C. SpineCor A non-rigid brace for the treatment of idiopathic scoliosis: post-treatment results. European Spine Journal 2003;12(2): Dolan 2007 Dolan L, Weinstein S. Surgical rates after observation and bracing for adolescent idiopathic scoliosis: an evidencebased review. Spine 2007;32(19):S Downs 1998 Downs S, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Journal of Epidemiology & Community Health 1998;52(6): Fallstrom 1986 Fallstrom K, Cochran T, Nachemson A. Long-term effects on personality development in patients with adolescent idiopathic scoliosis: influence of type of treatment. Spine 1986;11(7):

17 Freidel 2002 Freidel K, Petermann F, Reichel D, Steiner A, Warschburger P, Weiss Hans R. Quality of life in women with idiopathic scoliosis. Spine 2002;27(4):E Furlan 2009 Furlan AD, Pennick V, Bombardier C, van Tulder M, Editorial Board, Cochrane Back Review Group updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine 2009;34(18): Goldberg 2002 Goldberg C, Moore D, Fogerty E, Dowling F. The natural history of early onset scoliosis. Studies in Health Technology and Informatics 2002;91(SUPP 3): Grivas 2008 Grivas T, Vasiliadis E, Olga D, Triantafyllopoulos S, Triantafyllopoulos G. What a school screening program could contribute in clinical research of idiopathic scoliosis aetiology. Disability and Rehabilitation 2008;30(10): Haher 2003 Haher T, Merola A. Atlas of Spine Surgical Techniques. 1. Vol. 1, New York, NY: Thieme, Hawes 2006a Hawes M. Impact of spine surgery on signs and symptoms of spinal deformity. Pediatric Rehabilitation 2006;9(4): Higgins 2011 Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version [updated March 2011]. The Cochrane Collaboration, Available from Chichester: John Wiley and Sons. Kadoury 2009 Kadoury S, Cheriet F, Beausejour M, Stokes I, Parent S, Labelle H. A three-dimensional retrospective analysis of the evolution of spinal instrumentation for the correction of adolescent idiopathic scoliosis. European Spine Journal 2009;18(1): Kanayama 1996 Kanayama M, Tadano S, Kaneda K, Ukai T, Abumi K. A. mathematical expression of three dimensional configuration of the scoliotic spine. ASME Journal of Biomechanical Engineering 1996;2(118): Katz 2001 Katz D, Durrani A. Factors that influence outcome in bracing large curves in patients with adolescent idiopathic scoliosis. Spine 2001;26(21): Knott 2010 Knott P, Mardjetko S, Rollet M, Baute S, Riemenschneider M, Muncie L, et al. Evaluation of the reproducibility of the formetric 4D measurements for scoliosis. Scoliosis 2010;5 (Suppl 1):O10. Lenssinck 2005 Lenssinck ML, Frijlink AC, Berger MY, Bierman-Zeinstra SM, Verkerk K, Verhagen AP, et al. Effect of bracing and other conservative interventions in the treatment of idiopathic scoliosis in adolescents: a systematic review of clinical trials. Physical Therapy 2005;85(12): Lonner 2007 Lonner BS, Kondrachov D, Siddigi F, Hayes V, Scharf C. Thoracoscopic spinal fusion compared with posterior spinal fusion for the treatment of thoracic adolescent idiopathic scoliosis. Surgical technique.. American Journal of Bone Joint Surgery 2007;Suppl 2(1): Lonstein 2006 Lonstein JE. Scoliosis: surgical versus non-surgical treatment. Clinical Orthopaedics and Related Research 2006; 443(1): Lupparelli 2002 Lupparelli S, Pola E, Pitta L, Mazza O, De Santis V, Aulisa L, et al. Biomechanical factors affecting progression of structural scoliotic curves of the spine. Studies in Health Technology and Informatics 2002;91(1):81 5. Lykissas 2013 Lykissas M, Jain V, Nathan S, Pawar V, Eismann E, Sturm P, et al. Mid- to long-term outcome in adolescent idiopathic scoliosis after instrumented posterior spinal fusion: a metaanalysis. Spine 2013;38(2):E Maruyama 2008 Maruyama T, Takeshita K. Surgical treatment of scoliosis: a review of techniques currently applied. Scoliosis 2008;3(6): 1 6. Merola 2002 Merola A, Haher TR, Brkaric M, Panagopoulos G, Mathur S, Kohani O, Lowe TG. A multicenter study of the outcomes of the surgical treatment of adolescent idiopathic scoliosis using the Scoliosis Research Society (SRS) outcome instrument. Spine 2002;27(18): Negrini 2005 Negrini S, Aulisa L, Ferraro C, Fraschini P, Masiero S, Simonazzi P, et al. Italian guidelines on rehabilitation treatment of adolescents with scoliosis or other spinal deformities. Europa Medicophysica 2005;41(2): Negrini 2006c Negrini S, Marchini G. Efficacy of the symmetric, patientoriented, rigid, three-dimensional, active (SPoRT) concept of bracing for scoliosis: a prospective study of the Sforzesco versus Lyon brace. Europa Medicophysica 2006;43(2): Negrini 2010 Negrini S, Minozzi S, Romano M, Bettany-Saltikov JA, Chokalingham N, Grivas T, et al. Braces for idiopathic scoliosis in adolescents. Cochrane Database of Systematic Reviews 2010, Issue 1. [DOI: / CD pub2] Negrini 2012 Negrini S, Aulisa A, Aulisa L, Circo A, De Mauroy J, Durmala J, et al SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis 2012;7(1):3. 13

18 Noonan 1997 Noonan K, Dolan L, Jacobson W, Weinstein S. Long-term psychosocial characteristics of patients treated for idiopathic scoliosis. Journal of Pediatric Orthopaedics 1997;17(6): Odermatt 2003 Odermatt D, Mathieu P, Beausejour M, Labelle H, Aubin C. Electromyography of scoliotic patients treated with a brace. Journal of Orthopaedic Resources 2003;21(5): Olgun 2013 Olgun ZD, Yazic M. Posterior instrumentation and fusion. Journal of Children s Orthopaedics 2013;7(1): Oxborrow 2000 Oxborrow N. Methodology. Current topic: assessing the child with scoliosis: the role of surface topography. Archives of Disease in Childhood 2000;83(5): Pineda 2006 Pineda S, Bago J, Gilperez C, Climent J. Validity of the Walter Reed Visual Assessment Scale to measure subjective perception of spine deformity in patients with idiopathic scoliosis. Scoliosis 2006;1(1):18. Reichel 2003 Reichel D, Schanz J. Developmental psychological aspects of scoliosis treatment. Pediatric Rehabilitation 2003;6(34): Review Manager (RevMan) 2014 The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan) (Computer program) Rigo 2006a Rigo M, Negrini S, Weiss H, Grivas T, Maruyama T, Kotwicki T, et al. SOSORT consensus paper on brace action: TLSO biomechanics of correction (investigating the rationale for force vector selection). Scoliosis 2006;1(1):11. Roaf 1980 Roaf R. Spinal Deformities. 2nd Edition. Tunbridge Wells: Pitman Medical, Romano 2012 Romano M, Minozzi S, Bettany-Saltikov J, Zaina F, Chockalingam N, Kotwicki T, et al. Exercises for adolescent idiopathic scoliosis. Cochrane Database of Systematic Reviews 2012, Issue 8. [DOI: / CD pub2] Rowe 1997 Rowe D, Bernstein S, Riddick M, Adler F, Emans J, Gardner-Bonneau D, et al. A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis. The Journal of Bone & Joint Surgery 1997;79(5): Sanders 2007 Sanders J, Harrast J, Kuklo T, Polly D, Bridwell K, Diab M, et al. The Spinal Appearance Questionnaire: results of reliability, validity, and responsiveness testing in patients with idiopathic scoliosis. Spine 2007;32(24): Shekelle 1994 Shekelle P, Andersson G, Bombardier C, Cherkin D, Deyo R, Keller R, et al. A brief introduction to the critical reading of the clinical literature. Spine 1994;19(19):2028S 31S. Smania 2008 Smania N, Picelli A, Romano M, Negrini S. Neurophysiological basis of rehabilitation of adolescent idiopathic scoliosis. Disability and Rehabilitation 2008;30 (10): Stokes 1996 Stokes I, Spence H, Aronsson D, Kilmer N. Mechanical modulation of vertebral body growth: implications for scoliosis progression. Spine 1996;21(10): Stokes 2006 Stokes I, Burwell R, Dangerfield P. Biomechanical spinal growth modulation and progressive adolescent scoliosis a test of the vicious cycle pathogenetic hypothesis: summary of an electronic focus group debate of the IBSE. Scoliosis 2006;1(1):16. Sutton 2000 Sutton A, Duval S, Tweedie R, Abrams K, Jones D. Empirical assessment of effect of publication bias on metaanalyses. BMJ 2000;320(1): Van Tulder 2003 Van Tulder M, Furlan A, Bombardier C, Bouter L, Editorial Board Cochrane Back Review Group. Updated method guidelines for systemic reviews in the Cochrane Collaboration Back Review Group. Spine 2003;28(12): Vasiliadis 2006 Vasiliadis E, Grivas T, Gkoltsiou K. Development and preliminary validation of Brace Questionnaire (BrQ): a new instrument for measuring quality of life of brace treated scoliotics. Scoliosis 2006;1(7):1 8. Weiss 2004 Weiss H, Hawes M. Adolescent idiopathic scoliosis, bracing and the Hueter-Volkmann principle. Spine Journal 2004;4 (4): Weiss 2006a Weiss H, Negrini S, Hawes M, Rigo M, Kotwicki T, Grivas T, et al. Physical exercises in the treatment of idiopathic scoliosis at risk of brace treatment-sosort Consensus Paper Scoliosis 2006;1(1):6. Weiss 2006b Weiss H, Reichel D, Schanz J, Zimmermann-Gudd S. Deformity related stress in adolescents with AIS. Studies of Health and Technology Informatics 2006;123(1): Weiss 2008a Weiss H, Goodall D. Rate of complications in scoliosis surgery: a systematic review of the PubMed literature. Scoliosis 2008;3(9):1 18. [DOI: / ] 14

19 Weiss 2008b Weiss H. Adolescent idiopathic scoliosis (AIS) an indication for surgery? A systematic review of the literature. Disability and Rehabilitation 2008;30(10): Weiss 2008c Weiss H, Goodall D. The treatment of adolescent idiopathic scoliosis (AIS) according to present evidence. A systematic review. European Journal of Physical Rehabilitation Medicine 2008;44(2): Weiss 2013 Weiss H, Moramarco M, Moramarco K. Risks and longterm complications of adolescent idiopathic scoliosis surgery vs. non-surgical and natural history outcomes. Hard Tissue 2013;2(3):27. Westrick 2011 Westrick E, Ward W. Adolescent idiopathic scoliosis: 5- year to 20-year evidence-based surgical results. Journal of Pediatric Orthopaedics 2011;31(1 suppl):s61 8. White 1990 White A, Panjabi M. Chapter 7. Functional analysis and clinical applications. Clinical Biomechanics of the Spine. 2nd Edition. Baltimore: Lippincott, Indicates the major publication for the study 15

20 C H A R A C T E R I S T I C S O F S T U D I E S Characteristics of excluded studies [ordered by study ID] Study Anderson 2006 Bunge 2007 Danielsson 2001 Danielsson 2001a Danielsson 2001b Danielsson 2003 Danielsson 2006 Pehrsson 2001 Reason for exclusion Retrospective study with a control group Retrospective cross sectional study with a control group Retrospective study with a control group Retrospective study with a control group Retrospective study with a control group Retrospective study with a control group Retrospective study with a control group Retrospective study with a control group 16